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James Sidas is an exceptionally brilliant physicist and author who traded his successful career for a job as a courier. The youngest person to ever graduate MIT, he has an IQ of 178 and published three books and 35 papers all before the age of 18. He is portrayed by actor Esteban Powell. It is possible that Shore based Sidas on William James Sidis, a mathematical and linguistic prodigy.
Sidas was admitted to hospital when he found himself disoriented and unable to control the movement of his hand. On examination, he was found to have ataxia, anemia and a mild cough. His CT Scan was clear and his tox screen was negative. Dr. Hadley thought it might be a virus like West Nile virus. However, Sidas had no fever and his lymph nodes weren't swollen. Dr. Taub thought it might be hyperbilirubinemia, and Dr. Chase thought it was meningitis. Dr. Taub suggested sickle cell anemia even though the patient was of European descent. Dr. Foreman thought it was Thrombotic thrombocytopenic purpura and Dr. Hadley and Dr. Chase agreed. Dr. House cut off the discussion and ordered a blood smear to confirm and a test of his ADAMTS13 antibodies.
Dr. Hadley reported the diagnosis to Sidas and his wife. She told them TTP wasn't curable, but it was treatable. Dr. Taub started to ask why he wasn't working at a better job, but Sidas realized that Dr. Taub was trying to find out if he was an alcoholic or drug addict. Dr. Taub also asked if he had a history of mental illness. Sidas assured him he was working as a courier by choice and he was happy doing it.
Dr. Taub asked Dr. Hadley if she found anything odd about Sidas. She said he seemed normal, but Dr. Taub said that was the problem - people with high IQs generally don't act normal. Sidas's blood tested positive for schistocytes, confirming TTP. However, Dr. Taub thought it wasn't the whole story - the case was too easy for Dr. House. He figured there was another condition and Dr. House was testing his fellows to find out if they would catch on.
Dr. Taub and Dr. Hadley reported the results to Dr. House, but they said that plasmapheresis wasn't an option because the patient had an albumen colloid allergy. The alternative was a spleenectomy. Dr. House agreed. When Dr. Taub asked him why he took such an easy case, Dr. House said he wanted to meet the patient.
The surgery went well and Sidas appeared to be recovering. He would need long term medication, but Dr. Chase assured Sidas that he would be released in about a week if everything went well. However, when Sidas started talking, he wasn't making sense. His vital signs monitor set off an alarm. After examining him, Dr. Chase realized he was having a stroke. He was given oxygen.
Sidas's stroke was successfully treated and there was no permananent brain damage. However, it appeared that they had done the spleenectomy for nothing. Although the symptoms and tests all pointed to TTP, it wouldn't explain why he failed to improve after the spleenectomy. Dr. Taub thought it might be CNS vasculitis, but something would have shown up on the CT Scan. Dr. Hadley thought it might be DIC, but there was no hemmorhaging. Dr. Taub suggested acquired pancytopenia, but the patient's WBC count was normal. Dr. Foreman thought it might be a toxin and Dr. Chase pointed out non-standard toxins don't show up on a tox screen. Dr. House ordered an environmental scan and tests for non-standard toxins that might cause the symptoms.
Dr. Taub and Dr. Chase did the environmental scan. Dr. Chase found ibuprofen, nose drops and cough syrup. Dr. Taub found signs of mice and realized leptospirosis could have caused the ataxia and anemia, but Dr. Chase thought he would have to have a fever. They also found his old physics notebooks which were at least 14 years old. Dr. Taub realized that Sidas was passionate about physics in his youth and couldn't figure out why he gave it up. However, Dr. chase then noticed an air vent was loose and found a large empty vodka bottle.
The screen for other toxins was also negative. Dr. Chase thought it was liver failure from alcohol. Dr. House ordered Dr. Taub and Dr. Hadley to do a liver biopsy even though they were about to leave for Thanksgiving.
Sidas denied being an alcoholic, but his wife was surprised he drank at all. Dr. Taub performed the biopsy, but Sidas thought it was a waste of time. However, the results showed no cirrhosis, scarring or infection. The blood tests showed only one abnormal result, an albumen level of 7.2. That could be explained by kidney failure. It would also explain the anemia and if he developed hyperkalemia it would explain the ataxia. The stroke could be explained by ischemic encepalopathy. However, they realized they would have to stay to test his kidneys.
Dr. House was away the following day so Dr. Foreman started the new differential for kidney failure. Dr. Hadley thought it might be rhabdomyolysis, but there was no edema. Dr. Chase thought it might be multiple myeloma, but there was no bone pain. He then suggested polycystic kidney disease, but there were no UTIs or flank pain. Dr. Chase started thinking about the cough the patient had at admission. Dr. Hadley said the patient wasn't coughing now, but Dr. Chase had also found cough syrup. Dr. Taub thought it might be Goodpasture's syndrome, which would affect the kidneys and lungs. Dr. Foreman wanted to start him on immunosuppressants and dialysis. Dr. Hadley wanted to check with Dr. House, but as the rest of the team was in agreement, they decided that it wasn't necessary.
They told Sidas he would need to be on dialysis for 4-6 hours a day until they saw improvement. If they didn't see improvement, he would need a transplant.
However, Dr. House returned to the hospital realizing that Sidas' lack of intelligence was the sign of dextromethorphan abuse. He was deliberately using it to lower his intelligence as it was cheap and widely available. However, he would suffer permanent brain damage unless he also used alcohol to counter the effect, explaining the vodka bottle. He admitted he did it to feel less miserable. Dr. House told him that the dextromethorphan abuse explained all his symptoms. Dr. House ordered a lavage of his small intestine and activated charcoal to remove it from his system.
Sidas started to improve and he began work in applied physics, "doodling" a schematic for a toroidal helicon plasma device. However, he confided in Dr. Foreman that he was feeling miserable again and that he felt less attracted to his wife. He admitted he was a jerk and he owed her everything, but he didn't want to be with her.
Even his wife realized that he had changed and didn't want to be with her anymore. Dr. Foreman tried to assure her that it was just withdrawal symptoms. However, Sidas called for help. He said he couldn't feel anything in his legs. Dr. Foreman realized he was unresponsive to stimuli - paralysis.
Dr. Hadley suggested Vitamin B12 deficiency, which would explain the anemia and numbness, but wouldn't explain the stroke. Dr. Hadley thought it might be a vascular malformation, but the anemia wasn't macrocytic. Dr. Foreman suggested a bone marrow malignancy, but this would not explain the schistocytes. Dr. Taub suggested lupus, but his ANA was negative.
Dr. House went to the patient for assistance, but he didn't think he would be able to help. Sidas admitted that twelve years before, he tried to commit suicide by jumping off an 8 story building into a dumpster. He broke a leg and three ribs. While he was on narcotics, he realized he wasn't as intelligent and it made him less depressed, isolated and lonely. That's when he met his wife - she was dumb (IQ 87) and happy, and he realized he wanted to stay less intelligent forever. Dr. House felt empathy for the like-minded individual and gave him a bottle of cough syrup, so that "Einstein could give himself a lobotomy". However, he also realized his broken ribs might be relevant. Sidas confirmed he broke the bottom three on his left side, just where his spleen was.
Dr. House planned an MRI with ferrous oxide contrast because it would be absorbed by the spleen. However, he realized if the patient had no spleen, the contrast would be absorbed by the liver and would severely damage it. Dr. Chase was incredulous that Dr. House thought he would operate and not remove the spleen. However, when they did the scan, they found several accessory spleens, most likely created when his spleen was damaged by his broken ribs. They realized it was TTP all along, Dr. Chase just didn't remove all of the spleens - there were 16 remaining that had to be removed. Dr. Chase planned more surgery.
The further surgeries went well. However, Sidas admitted he was going to return to dextromethorphan abuse.
A Reflection of House
Reaching the Diagnosis
The team starts with ataxia, a loss of the voluntary control of muscle movement. It often manifests in gait or speech, but here it's a problem with the patient's hands. His initial tests also show anemia, and he has a mild cough. A CT Scan and tox screen are clear. House rules out an infectious cause as the patient has no fever and his lymph nodes aren't swollen. However, when Foreman suggests thrombotic thrombocytopenic purpura, everyone except Taub sees it as a good fit. House orders a blood smear and a test for adamts13 antibodies.
However, after the splenectomy, the patient suffers a stroke.This seems to rule out TTP. Central nervous system vasculitis presents with similar systems, but would have been seen on a CT Scan. Disseminated intravascular coagulation is ruled out because there is no bleeding. Pancytopenia was also suggested, but the patient's white blood cell count is normal. Foreman suggests a toxin and, despite the clean tox screen, House orders an environmental scan.
The environmental scan finds mouse droppings, but leptospirosis is immediately eliminated due to the lack of a fever. However, they find alcohol hidden in a vent, and liver failure explains all the symptoms. House orders a liver biopsy to confirm despite the patient's denial that he's an alcoholic. When the biopsy is normal, they realize the patient probably wasn't lying, and their attention turns to his kidneys due to an elevated albumen level. However, hyperkalemia would only explain the patient's ataxia, not the stroke. Taub suggests that may have been caused by ischemic encephalopathy. They decide to test his kidneys. .
The testing confirms decreased kidney function. Rhabdomyolysis is suggested as the cause, but there is no edema associated with trauma. Multiple myeloma is ruled out because there is no bone pain. Polycystic kidney disease is ruled out due to a lack of urinary tract infection or flank pain. Their attention turns to the cough medicine found during the environmental scan. Goodpasture syndrome would explain the kidney failure and cough, so the team decides to start him on dialysis and immunosuppresants.
However, House comes up with another use of the cough medicine. He realizes that Sidas, a genius, is operating at below normal intelligence levels and determines, correctly, that his is taking dextromethorphan to decrease his intelligence, but alcohol to prevent permanent damage to his brain. House realizes the dextromethorphan abuse explains all his symptoms and orders an intestinal lavage and activated charcoal to remove it from his system.
Sidas improves quickly, and his intellect quickly returns. However, he's soon suffering from complete numbness in his legs. Vitamin B12 deficiency would explain the anemia and numbness, but not the stroke. Arteriovenous malformation is ruled out almost immediately because the anemia would be characterized by abnormally large red blood cells. Bone marrow malignancy is ruled out because there would be no schistocytes. Lupus is ruled out because his ANA was normal.
Without any ideas, he goes to see the patient and, while they are talking, he finds out Sidas broke three ribs when he attempted suicide. House realizes the trauma resulted in accessory spleens. He orders an iron oxide scan to confirm, then orders the sixteen accessory spleens removed.
Explaining the Medicine
- Dextromethorphan won't show up on a standard tox screen, although it may cause a false positive for opiates or phencyclidine.
- A patient with TTP will have shistocytes visible on their blood smear
- The adamsts13 gene is involved in the clotting process. In TTP, the results for gene activity, the gene inhibitor, and autoantibodies against the gene can point to a genetic cause for the condition.
- In plasmapherisis, albumin colloid is used to help replace the patient's plasma. It's the preferred choice because allergic reactions are rare, but Sidas is allergic to it.
- It is not well understood why a splenectomy is effective in treating TTP, but it appears the spleen plays a key role in the formation of adamsts13 antibodies.
- Vasculitis shows up on a CT Scan because the disease affects the blood vessels themselves.
- As its name suggests pancytopenia means levels of red blood cells, white blood cells and platelets are all low. As such, James's normal white blood cell count rules it out.
- OTIS CAMPBELL is a mnemonic for the types of toxic exposure. MOIST PLLACEB is an anagram
- Linking high serum albumen to kidney disease is a bit of a stretch. With kidney disease, albumen levels are elevated in the urine, not the blood. High levels in the blood usually indicate either dehydration or a diet high in protein.
- Potassium is key to the functioning of nerves. Either low or high levels can interfere with proper nerve function and lead to ataxia
- Although most strokes are caused by a blockage, a person can suffer stroke like symptoms if they do not receive sufficient oxygen for any reason.
- Rhabdomyolosis releases proteins, particularly myoglobin into the bloodstream which are poisonous to the kidneys.
- Similarly, multiple myeloma also produces by-products that can damage the kidneys.
- In high enough doses, dextromethorphan acts as a dissociative anesthetic, resulting in a decrease in brain function. When mixed with alcohol, the sedative effects are increased while the stimulant effects are decreased.